Children s Hospital Los Angeles 2025

1. Click ‘Get Form’ to open the Consultation Request Form in the editor.
2. Begin by filling in the 'Referring Facility' section with the name of your institution. Ensure all details are accurate.
3. Enter the 'Date' of the request, followed by the 'Ordering Physician Name'. This is crucial for processing your request.
4. Provide your signature and contact information, including phone and fax numbers, to facilitate communication.
5. In the 'MATERIAL SUBMITTED' section, fill in patient details such as first name, last name, age, date of birth, and sex. This information is mandatory.
6. Complete the 'Path #' and material counts for blocks and slides. Ensure that you include a collection date for accuracy.
7. For billing information, specify the billing contact person and their institution. Include complete address and contact details.

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